GERD Pathophysiology

Question 1

Pathophysiology of GERD?

Answer 1

1/ Abnormal reflux of gastric contents from stomach → esophagus → impaired gastroesophageal LES pressure/function

Question 2

Cycle that leads to worsening of GERD?

Answer 2

Impaired LES function → Acid reflux → Esophageal mucosal acid contact time → Esophagitis → ↓ LES pressure

Question 3

GERD alarm sx

Answer 3

Difficulty (dysphagia = common) or pain (odynophagia) swallowing
Unexplained Weight loss & anemia
Wheezing/hoarseness/coughing Choking/aspiration
Chest pain indistinguishable from heartburn OR Undiagnosed chest pain
Nocturnal heartburn (night time)
Presence or history of vomiting blood Black, tarry, stool
Heartburn persisting while on rec dosages of OTC H2RAs or PPIs
Heartburn occurring ≥ 2 days/week lasting for > 3 months

Question 4

Why do we treat GERD?

Answer 4

To minimize & prevent complications:
Esophagitis
Hemorrhage
Perforation
Barrett’s esophagitis
Esophageal ulcers Strictures
Aspiration Induction of asthma attacks
Esophageal adenocarcinoma

Question 5

Goals of GERD therapy?

Answer 5

Treatment determined by disease severity Alleviate sx
Diminish frequency/duration of reflux
Promote esophageal healing
Prevent recurrence & complications
↑ QOL

Question 5

What is the step up method? Who is it for?

Answer 5

1. In pts w/ mild & intermittent sx & no evidence of erosive esophagitis
2. Start w/ less aggressive treatment
3. Begin w/ TLC → therapeutic lifestyle changes + least expensive or least potent med
   Antacid → H2HRA → PPI
4. Only “step up” to stronger therapy if sx are not controlled

Question 6

Typical presentations of GERD?

Answer 6

Sx often worse AFTER eating → May be relieved w/ repeated swallowing
Heartburn → Sub-sternal pain/warm sensation
Regurgitation/belching
Hypersalivation
Chest pain → Sometimes confused with angina

Question 7

Meds that are Direct irritants to esophageal mucosa

Answer 7

ASA Bisphosphonates NSAIDs Iron
KCl Quinidine

Question 8

foods that are Direct irritants to esophageal mucosa

Answer 8

Spicy foods OJ Tomato juice Coffee
Tobacco

Question 8

Meds that ↓ LES tone

Answer 8

Anticholinergics Barbiturates DHP CCB Dopamine Agonists
Estrogen/progesterone Nicotine Nitrates Theophylline
TCAs

Question 9

Foods that ↓ LES tone

Answer 9

Fried, fatty foods Chocolate EtOH Coffee, tea, soda
Citrus Tomatoes Peppermint Garlic, onions

Question 10

4 Impaired mucosal defense mechanisms

Answer 10

Impaired esophageal clearance
Abnormal esophageal anatomy
↓ mucosal resistance to acid
Delayed gastric emptying

Question 11

4 things that cause ↓ LES pressure

Answer 11

Spontaneous, transient LES relaxation
Transient ↑ in intra-abdominal, esophageal pressure → pregnancy, obesity
Atonic LES
Pharmacologic

Question 12

Non-pharm treatment for GERD

Answer 12

Avoid eating w/in 2-3 hrs of bedtime Avoid meds that lower LES
Elevate the head of the bed Smoking cessation
Weight loss Wear loose fitting clothing
Avoid foods that lower LES

Question 13

Pharm treatments for GERD?

Answer 13

Antacids H2RAs
PPIs Surface Agents
Prokinetics

Question 14

Frequenct GERD

Answer 14

Frequent → ≥ 2 episodes per week

Question 15

Mild & intermittent GERD

Answer 15

Mild & intermittent → < 2 episodes per week

Question 16

2 phases of GERD treatment

Answer 16

Initial treatment (get sx under control)
Maintenance therapy ( keep sx controlled once improved)

Question 17

Cons of step up method

Answer 17

Time consuming → Patients may spend a long time trying weaker therapies that don’t fully relieve sx
Not cost-effective → Multiple ineffective trials can cost more in visits + meds over time
Low quality of life (QOL) → pts keep experiencing sx while slowly moving through weaker treatments

Question 18

What is the step down method? Who is it for?

Answer 18

Step-down → in pts w/ erosive esophagitis, frequent sx
Start with TLC + a PPI → most effective & aggressive med
Once sx are controlled, step down to less potent therapy
PPI → H2HRA → Antacid
Once sx are controlled, the dose or intensity is stepped down.

Question 19

pros and cons of step down

Answer 19

Pros
Less time consuming
More cost-effective
Improved QOL
Cons → Pts might start on PPIs & never step-down

Question 20

When does maintenance therapy play a role?

Answer 20

Maintenance therapy → after sx are controlled

Question 21

What happens when you relapse during step down

Answer 21

Relapse → step up to the previously effective therapy

Question 22

What is on-demand therapy? What happens if sx return?

Answer 22

Pt takes med only when sx occur Continue agent until sx are controlled, then stop. If sx returns, restart the med & use until sx-free for 24 hours, then stop again.

Question 22

When is it mild GERD? What is the treatment? What is the goal?

Answer 22

→ Sx <1 week or mild intensity TLC + OTC or Rx H₂RA, or PPI for 2 weeks Goal → Symptomatic relief w/ short-term therapy

Question 23

What is intermittant therpy? What happens if sx return?

Answer 23

Take med for a defined short course when sx flare The agent is taken until sx are controlled, then stopped. If sx returns, resume therapy for a 2-4 wks, then stop.

Question 24

When is it moderate to severe GERD? What is the treatment? What is the goal?

Answer 24

more frequent sx → more bothersome, TLC + Rx PPI for 4–8 weeks H₂RAs may be considered BUT PPIs → more effective. Goal → reduce acid exposure more aggressively because sx happen more often

Question 25

What is the treatment for Esophagitis or complications? What is the goal?

Answer 25

TLC + Rx PPI BID for 4–16 weeks, or Anti-reflux surgery Goal → treat more aggressively to heal mucosal damage & prevent progression